Internal Medicine

P1: SBT

0521779407-04 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:8

174 Asthma

➣Low-dose inhaled steroid+long-acting beta-agonist+rescue

beta-agonist PRN, or

➣Low-dose inhaled steroid+LTRA+rescue beta-agonist PRN

■Severe persistent:

➣High-dose inhaled steroid+long-acting beta-agonist+rescue

beta-agonist PRN, or

➣High-dose inhaled steroid+LTRA+rescue beta-agonist PRN, or

➣High-dose inhaled steroid+long-acting beta-agonist+LTRA+

rescue beta-agonist PRN, or

➣Oral steroids+high-dose inhaled steroid+long-acting beta-

agonist+LTRA+rescue beta-agonist PRN

■Nonresponsive patients rare; some respond better to one agent than

another

■Most failures due to undertreatment, or failure to appreciate severity

■Theophylline or nedocromil: alternative but less-effective con-

trollers

■Salmeterol should not be used as monotherapy: more exacerbations

than with inhaled steroids

■If symptoms resolve with treatment, continue×1–3 mo before step-

ping down slowly

■If symptoms persist, step-up; consider other diagnosis

Other Measures

■Environmental controls (mattress covers; no pets, smoke, carpets,

draperies) reduce bronchial hyperresponsiveness, frequency and

severity of asthma

■Annual influenza vaccine

■Peak flow monitoring detects asymptomatic deterioration; rein-

forces improvement with therapy; increases adherence to prescribed

medication regimen

■Smoking cessation

■Patient education (inhaler skills, rationale for meds, self-

management) improves asthma control, reduces morbidity and

mortality and costs

■Action plan=specific written instructions:

➣Daily medication regimen

➣How to recognize exacerbation

➣How to adjust medications

➣When to seek help

■Consider ASA, sulfite sensitivity, beta-blockers

■Treat comorbid conditions (allergic rhinitis, sinusitis, GERD)